Pain Management Coding Alert

Here’s the lowdown on coding for the critically ill or injured.

If a PM specialist is called upon to perform critical care, coders need to be ready to report the evaluation and management (E/M) codes carefully.

Why? There are some very specific rules for reporting 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (… each additional 30 minutes (List separately in addition to code for primary service)). Failure to follow these rules to the letter will likely result in a denial.

We’ve rounded up some experts and asked them to help coders nail the basics of critical care coding. Here’s what they had to say.

Q: When should the coder begin counting critical care minutes?

A: When coding for critical care, you cannot code for time spent in pre-hospital medical direction or coordination of care — activating alerts, setting up rooms/staff, etc. — prior to the patient arriving Critical care time can only begin once the patient arrives, says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

“All CPT^® E/M codes assume pre-work and this is built into the relative value. For instance, 99291 includes 15 minutes of pre-service time according to the AMA’s RBRVS [resource-based relative value scale] database,” Witt continues.

Also, CPT^® guidelines for critical care state “critical care is the direct delivery by a physician .... of medical care for a critically ill or critically injured patient. Direct care means the physician is present and directly involved in the care,” says Witt.

In addition to CPT^®, Medicare “has been very clear that they only accept critical care time spent with the patient, or on the floor with the patient,” confirms Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. “This makes a certain amount of sense because the critically ill patient is one who might need an intervention at any time. If the patient isn’t there, then it is not possible to intervene. Also, it’s impossible to have truly assessed the severity of the patient’s condition if the provider hasn’t seen the patient yet.”

Q: What does “critically ill or injured” mean?

A: This is an important concept to master, since CPT^® states that a patient must be critically ill or injured in order to use critical care codes. The introduction to the critical care codes includes a very descriptive rundown of what’s considered critically ill or injured—and you should definitely familiarize yourself with that section. However, one expert summed it up thusly:

“Critically ill or injured implies that [without critical care] there is a risk of loss-of-life or loss-of-function/further loss-of-function of a major organ and or organ system, with an acute or exacerbated presentation of the condition,” explains Joshua Tepperberg, CPC, senior coding analyst at caduceus inc., in Jersey City, New Jersey. For example, acute respiratory failure, cardiac failure, kidney failure, metabolic failure, brain injury, and major traumas.

Q: If your physician provides less than 30 minutes of critical care, what should you report?

A: The descriptor for 99291 states that the physician needs to perform at least 30 minutes of critical care in order to report the code. So what do you do if the physician performs less than 30 minutes of critical care on a patient?

Choose the appropriate evaluation and management (E/M) based on encounter specifics, says

Jill Young, CPC, CEDC, CIMC, owner of Young Medical Consulting in East Lansing, Michigan. The location of the critical care will be a factor in the E/M code set you choose from, Young reminds.

“Because critical care has no location restrictions, care of less than 30 minutes is coded with an E&M service appropriate for the setting/location,” she says.

Q: What are some of the top locations that critical care occurs?

A: “Although critical care can be provided almost anywhere, based on the patients’ condition the top places to see critical care visits performed are the ICUs [intensive care units], emergency department, and observation unit,” explains Tepperberg. “Many hospitalists see their critical care cases on rapid response calls to the regular floors as well.”

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